Download - Angina Pectoris Complete
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 1/80
4/14/12
Angina Pectoris
Tutor : Prof. Dr. Nahed Baddour
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 2/80
4/14/12
Angina Pectoris
ID number Name Topic
10-2-161 Muhammad Bin Misbah introduction about Ischemic heart disease
10-2-162 Muhammad Jailani Bin Mustafa risk factors of Ischemic heart disease
10-2-163 Muhammad Hazim Bin Zulkifli classification of Ischemic heart disease &introduction about angina
10-2-164 Muhammad Hasif Bin Ramli aetiology, morphology, pathogenesis of stable angina
10-2-165 Muhammad Hafiz bin Mohamad Radzi clinical features, fate or complications of stableangina
10-2-166 Muhammad Huzaifah bin Hassan aetiology, morphology, pathogenesis of unstableangina
10-2-167 Mohd Hafizuddin B Md Nasir clinical features, fate or complications of unstableangina
10-2-168 Mohd Ridwan Shahputra bin Shihabuddin aetiology, morphology, pathogenesis of variantangina
10-2-169 Muhammad Ridzwan bin Abd Aziz clinical features, fate or complications of variantangina
10-2-170 Mohamad Zaimey bin Zulmanaf differences between each type of angina and
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 3/80
4/14/12
Angina Pectoris
introduction about Ischemicheart disease
Muhammad Bin Misbah
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 4/80
4/14/12
• Definition: group of closelyrelated disorders resultingimbalance betweenmyocardial demand andvascular supply of oxygenated blood.
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 5/80
4/14/12
Etiology of IschemicHeart Disease
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 6/80
4/14/12
1) Decrease
coronary blood flow
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 7/80
4/14/12
Coronaryatherosclerosis
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 8/80
4/14/12
Aortic regurgitation &stenosis
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 9/80
4/14/12
2) Increased
myocardial demand
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 10/80
4/14/12
Tachycardia
Hypertrophy
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 11/80
4/14/12
3) Factors thataggravate the
effects of ischemia
(hypoxia)
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 12/80
4/14/12
cyanotic congenitalheart disease
advanced lun
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 13/80
4/14/12
4) Diminishedoxygen carrying
capacity
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 14/80
4/14/12
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 15/80
4/14/12
Anemia
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 16/80
4/14/12
Angina Pectoris
classification of Ischemicheart disease &
introduction about angina
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 17/80
Click to edit Master subtitle style
4/14/12
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 18/80
Click to edit Master subtitle style
4/14/12
Classification of IschemicHeart Disease (IHD)
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 19/80
Click to edit Master subtitle style
4/14/12
ANGINA PECTORIS• It is characterized by intermittent chest pain.• The pain may radiate to the neck, back, down and left arm.
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 20/80
Click to edit Master subtitle style
4/14/12
ANGINA PECTORIS
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 21/80
Click to edit Master subtitle style
4/14/12
ACUTE myocardialinfarction (MI)
• MI, popularly called heart attack , is necrosis of heart muscleresulting from ischemia.
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 22/80
Click to edit Master subtitle style
4/14/12
ACUTE myocardialinfarction (MI)
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 23/80
Click to edit Master subtitle style
4/14/12
ECG CHANGES INMYOCARDIAL INFARCTION
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 24/80
Click to edit Master subtitle style
4/14/12
Chronic ischemic heartdisease
• Is essentially progressive heart failure as a consequence of ischemic myocardial damage.
• The heart isenlarged.
• Moderate tosevere
atherosclerosis
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 25/80
Click to edit Master subtitle style
4/14/12
SUDDEN CARDIAC DEATH
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 26/80
Click to edit Master subtitle style
4/14/12
SUDDEN CARDIAC DEATH(SCD)• Sudden Cardiac Death (SCD) is most commonly defined as
unexpected death from cardiac causes either without
symptoms or within 1 to 24 hours of symptom onset• The ultimate mechanism of SCD is most often a lethal
ARRYTHMIA, such as VENTRICULAR FIBRILLATION.
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 27/80
4/14/12
Angina Pectoris
Risk factors of Ischemicheart disease
Muhammad ailani
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 28/80
4/14/12
Hypertension (high bloodpressure)
• blood pressure can vary with activityand with age
• healthy adult generally has a systolicpressure reading between 120 and130 and a diastolic pressure readingbetween 80 and 90 (or below)
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 29/80
4/14/12
Diabetes
• heart problems are the leading causeof death with diabetes
• case of non-insulin-dependentdiabetes also known as Type IIdiabetes
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 30/80
4/14/12
High blood cholesterol
• cholesterol is a fat-like substancecarried by blood
• liver produces all of the cholesterolto form cell membranes and to makecertain hormones
• Extra cholesterol -meats, eggs,andother similar products
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 31/80
4/14/12
obesity and overweight
• increased total cholesterol levels,high blood pressure, and anincreased risk of coronary artery
disease• Developing other risk factors for
heart disease:
- high blood pressure
- high blood cholesterol
-diabetes
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 32/80
4/14/12
Smoking
• smoking increases the risk of lungcancer
• increases the risk of heart diseaseand peripheral vascular disease
• increases the risk of stroke in peoplewho already have high bloodpressure.
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 33/80
4/14/12
Angina Pectoris
aetiology, morphology,pathogenesis of stable
angina
WHAT IS
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 34/80
Click to edit Master subtitle style
4/14/12
WHAT ISSTABLE
ANGINA ???
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 35/80
4/14/12
WHEN IT WILL
HAPPEN???
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 36/80
4/14/12
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 37/80
4/14/12
WHICH PART THAT
YOU WILL FEEL PAIN???
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 38/80
4/14/12
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 39/80
4/14/12
FOR HOW LONG ???
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 40/80
4/14/12
ETIOLOGY
ü Coronary heart disease
ü Abnormal heart rhythms
ü Anemia
ü Coronary artery spasm
ü Heart failure
ü
Heart valve diseaseü Hyperthyroidism
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 41/80
4/14/12
ü Cold weather
ü Exercise
ü Emotional stress
ü Large meals
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 42/80
4/14/12
PATHOGENESIS
Ø Your heart muscle is working all the time, so itneeds a constant supply of oxygen. This oxygenis provided by the coronary arteries, which carryblood.
Ø When the heart muscle has to work harder, itneeds more oxygen. Symptoms of angina occur
when the coronary arteries are narrowed or blocked by hardening of the arteries(atherosclerosis), or by a blood clot.
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 43/80
4/14/12
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 44/80
4/14/12
Angina Pectoris
Symptoms andComplications of Stable
Angina
Muhammad Hafiz bin Mohamad Radzi
10-2-165
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 45/80
4/14/12
•
Common Symptoms
v tightness, heavy pressure, orsqueezing or crushing chest pain
Ø Occurs after activity or stress
Ø Lasts an average of 1 - 15 minutes
Ø Is relieved with rest or a medicinecalled nitro l cerin
Symptoms
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 46/80
4/14/12
• Other symptoms
v feeling of indigestion or heartburn
v Dizziness or light-headedness
v Nausea, vomiting, and sweating
v Palpitations
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 47/80
4/14/12
•
Cardiac arrhythmias
v Ventricular tachycardia
v Heart block
v Atrial fibrillation
v Congestive heart failure
Complications
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 48/80
4/14/12
• Mitral regurgitation
v Pericarditis
v Pulmonary embolism
v Shock
v Stroke
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 49/80
4/14/12
• Sudden death
v Ventricular fibrillation
v Ventricular aneurysm
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 50/80
4/14/12
Angina Pectoris
aetiology, morphology,pathogenesis of unstable
angina
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 51/80
4/14/12
Ø Heart does not get enough bloodflow and 0xygen ~ Heart Attack
Ø Acute Coronary Syndrome, norelease of the enzyme andbiomarkers of myocardial necrosis
Ø Braunwald Classification:Ø Class I : Less 2 months without rest
pain
Ø Class II : Next 48 hours + rest pain
Definitions
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 52/80
4/14/12
Etiology & pathogenesis
Ø Characteristic:Ø High frequency of pain
Ø Precipitated by progressively less exertion
Ø Episodes tend to be more intense and
– longer lasting than stable angina
Ø Pathogenesis:Ø Associated with plaque disruption + superimposed
partial thrombosis + distal embolization of thethrombus + vasospasm
F f i l
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 53/80
4/14/12
Factors of etiology
Ø Factors of etiologyØ Supply-demand mismatch
Ø Plaque disruption or rupture
Ø ThrombosisØ Vasoconstriction
Ø Cyclical flow
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 54/80
4/14/12
Angina Pectoris
clinical features, fate orcomplications of unstable
angina
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 55/80
Click to edit Master subtitle style
4/14/12
Clinical Features, Fate and Complication of Unstable Angina
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 56/80
4/14/12
Focused History &Physicalexamination
• There is chest pain in the :-substernal lesion orepigastrium radiating to neck-left shoulder and left arm.
• There is severe discomfort orpain.
• Anginal equivalents likedyspnoea and epigastricdiscomfort are also frequentlypresent.
• There is diaphoresis (increasedsweating), pale skin, sinustachycardia, third and fourthheart sound, basilar rales orcrepts, sometime hypotension.
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 57/80
4/14/12
•Angina starting within the past 2 months and
becoming more severe.
•Limiting their physical activity.
•Suddenly becoming more frequent, severe, or
longer-lasting or being brought on by less exertion
than before.
•Occurring at rest with no obvious exertion or stress.
Some say these symptoms may wake you up.
•Not responding to rest or nitroglycerin.
•Have other than common symptom is chest pain or
pressure symptoms like shortness of breath, nausea,and back or jaw pain (for woman).
PatientsComplaints:
ECG of unstable angina
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 58/80
4/14/12
ECG of unstable angina
• There is ST segment depression
•Rarely there is transient ST segment
elevation
• There may be T inversions
•Any new ST segment changes like
depression of even 0.05 mV may denote
increasing severity.
•New deep T wave inversions (more than 0.3
mV) may be significant, but usually T wave
changes are nonspecific.
Cardiac biomarkers for
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 59/80
4/14/12
•CK-MB and troponin (highly specific) are elevated
in MI and associated with increased risk of death.
•New cardiac markers are C-reactive protein, BNP
(B type nitriuretic peptide, CD-40 ligand etc.
Cardiac biomarkers forunstable angina
Fate of Unstable angina
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 60/80
4/14/12
Fate of Unstable angina
Prognostic indicators
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 61/80
4/14/12
Prognostic indicators
• Of note, studies have shown that the
following are significant
prognosticators for poor outcome:
• Ongoing congestive heart failure
• Presence/history of poor left
ventricular ejection fraction (LVEF)
•
Risk factors for coronary artery
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 62/80
4/14/12
y ydisease include:
• Diabetes
• Family history of early coronary heartdisease -- a close relative such as asibling or parent had heart diseasebefore age 55 (in a man) or beforeage 65 (in a woman)
• High blood pressure
• High LDL cholesterol
•
Low HDL cholesterol
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 63/80
4/14/12
Angina Pectoris
aetiology, morphology,
pathogenesis of variant
angina
Mohd Ridwan Shahputra bin
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 64/80
4/14/12
What is variant angina?
• Prinzmetal• A form of chest pain, pressure, or
tightness (angina)• Extremely rare• N.B; the American cardiologist Dr.
Myron Prinzmetal• A form of unstable angina
• No identifiabletrigger
• Occur in clusters
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 65/80
4/14/12
CoronaryVasospasm
Atherosclerosis
Injury to liningof artery
NervousSystem /
Muscle Tissue
Causes
Acetylcholine
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 66/80
4/14/12
Acetylcholine
ParasympatheticNervous System
DirectMechanism
Dilatation of Coronary
Arteries
inducesvasoconstriction of vascular smooth
muscle cells
stimulatesendothelial cellsto produce NO
Mechanism
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 67/80
4/14/12
Mechanism
Defect inendothelial Nitric
Oxide(NO)synthetase
enzyme
Reduced NO
Contraction of coronary vascular
smooth muscle
Endothelialfunction
abnormalities
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 68/80
4/14/12
Risk factor
• Substance abuse
• Traditional cardiovascular risk factors
•
Exercise• Alcohol withdrawal
• Hyperventilation
• Hypertension
• Diets high in salt and saturated fats
•
Obesity• Diabetes
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 69/80
4/14/12
Angina Pectoris
clinical features, fate orcomplications of variant
angina
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 70/80
4/14/12
Clinical features•
Occurs at rest• Last for 5-30 mins( between 12 – 8 AM )• Painful headache & Raynaud’s
phenomenon• Elevation of ST segment ( must be
detected during attack, suggestingprovocative method)
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 71/80
4/14/12
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 72/80
4/14/12
Fate
• Generally good prognosis
• Needs follow-up by doctors
• Treated with Calcium channel blockerand nitrates(vasodilators)
• In coronary blockade, angioplasty maybe considered.
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 73/80
4/14/12
Complications
• During pain, Arrhythmia mayoccur( vent. Tachycardia, vent.fibrillations, heart block)
• Treatment of arrhythmia may causemedication reaction & intolerance.
• For angioplastic patient; plaque
recurrence, infection, medicationreaction.
i i
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 74/80
4/14/12
Angina Pectoris
differences between eachtype of angina and
treatment
e
rences e ween ypesf A i
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 75/80
4/14/12
ypof Angina
Points of differences Stable (typical) Unstable
(pre-infarct)
Variant(Prinzmetal’s)
State Most common form More severe,frequent and lastlonger
Temporary suddennarrowing
Precipitated by 1. Exertion orphysical activity
2. emotional stress
(increase demand)
1. Less effort
2. even occurs atrest
1. Rest, awakenspatient from sleep
2. unrelated tophysical activity
Relieved by 1. Rest (to decreasedemand)
2. vasodilators (torelieve vasospasm)
1. Blood thinners(antiplatelet drugs)
2. Statins
1. vasodilators
2. calcium channelblockers
Coronary angiogram75% or more of atherosclerotic
narrowing
Non-occlusivecoronary thrombi
Near normal tosevere
atheroscleroticnarrowing
ECG analysis Depression of STsegment
1. ST segmentdepression
2. Rarely STsegment elevation
Elevation STsegment
Causes Fissuring ordisruption of the Coronary arterydisease due to Coronary vasospasm
M di i
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 76/80
4/14/12
Medications
S i l d
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 77/80
4/14/12
Surgical procedures
Angioplasty stentCoronary artery bypass graft
P ti
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 78/80
4/14/12
Preventions
R f
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 79/80
4/14/12
References
• PubMed Health : Stable angina, available from :http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001247/ [assessed at 4th April 2012]
• PubMed Health : Unstable angina, available from :http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH000125 0/
[assessed at 4th April 2012]
• PubMed Health : Variant angina, available from :http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH000121 2/ [assessed at 4th April 2012]
• Module 11 Semester 4 2011-2012 Year 2, TheCardiovascular System, Faculty of Medicine-AlexandriaUniversity : Heart Diseases, Ischaemic Heart Diseases(IHD), Classification of Ischaemic Heart Diseases, AnginaPectoris, page 208-210 [cited at 5th April 2012]
8/2/2019 Angina Pectoris Complete
http://slidepdf.com/reader/full/angina-pectoris-complete 80/80
Thank you